Bulimia nervosa is an eating disorder that impacts almost 2% of young women in America. Although men also struggle with it, the current literature notes a ten-to-one ratio of females to males who are diagnosed with this psychiatric condition. Individuals struggling with bulimia usually engage in binging behaviors, which are often followed by compensatory behaviors due to the guilt and shame associated with overeating.
The onset of bulimia nervosa is usually around puberty and the symptoms are heightened during the first few years of after high school. Bulimic behaviors sometimes manifest after a teenaged episode of dieting and weight gain during middle school and high school. Additionally, experiencing life stressors such as the divorce of one’s parents, loss, grief, and trauma can increase one’s vulnerability to development of this disorder. Many individuals who have a genetic disposition may not develop bulimia due to protective factors in their environments, such as effective coping mechanisms, high self-esteem, and good peer relationships.
Bulimia Nervosa has one of the highest co-morbidity rates of any psychiatric condition, appearing together with depression, anxiety, alcoholism, drug abuse, and personality disorders. Many clients I have seen throughout the years began therapy due to their struggles with other mental-health issues. It wasn’t until few months of therapy had passed that they felt comfortable disclosing their disordered eating behaviors. The shame and guilt associated with the binge/purge cycle are a key feature of this disorder.
For example, Maria (not her real name) and her family initially sought therapy due to communication issues following the separation of her parents. Maria’s mother’s alcohol use had been exacerbated in the last ten years of her marriage, and at one point she was no longer able to attend to her family’s needs.
As is the case with many other families experiencing a divorce, their stories were filled with anger, blame, and resentment toward each other. Although Maria’s mother had been in recovery for several years, the family still struggled with trusting her as part of the family. In our counseling sessions, I worked with them to establish new boundaries and work through their anger and depression.
From the moment I met the family, Maria struck me as a bright and sensitive teen. She was a star student throughout her middle-school and high-school years. She was finishing her senior year when her family first came to me. From an early age, she overcompensated for her mother’s alcoholism by cleaning for and looking after the entire family. She also became her father companion. All throughout her teenage years, she was the family’s rock, and everyone counted on her to be the family hero.
In our counseling sessions, we worked together to support her in effectively expressing to her parents her needs and feelings, and she regained her trust of her family. After six months of psychotherapy, I had been planning to terminate therapy with her and her family, since they had successfully achieved their initial treatment goals. It wasn’t until our initial pre-termination session that Maria shared with me that she had been struggling with bulimia nervosa for five years. In the chaos of her family, she had managed to keep it as a secret for all those years. While she was talking about her disordered eating behaviors for the first time in therapy, her shame was so deep that she was sobbing the entire time.
The same year, Maria was accepted to an Ivy League university. She planned to leave home that summer. When she first disclosed her eating disorder, she shared with me that she was thinking about turning down her admission, due to the severity of the symptoms of her eating disorder. She told me that she felt paralyzed by shame and had contemplated suicide for the past several months.
Binging is a key feature of bulimia nervosa. Binge eating refers to consuming a large amount of food in a discrete period of time (for example, within two hours). Often, individuals who binge experience a lack of control over their eating behaviors during these episodes, which are followed by the experience of shame and guilt.
For example, Maria told me that after her father left for his night shift, around 8 pm every night, she would eat three boxes of pre-made pasta, followed by two boxes of crackers, all within 30 minutes. She felt numb and was unable to stop after she began her binge cycle.
She had engaged in this behavior on average two to three nights a week for the past three years. Although the onset of her bulimia nervosa was during the year prior to her parents’ separation, the frequency of her binging and purging behaviors got worse after her mother left the house.
Maria’s binge episodes were often followed by immediate attempts to get rid of the food through self-induced vomiting. In addition to vomiting, the use of laxatives, diuretics, and other medications are other kinds of unhealthy compensatory behaviors that individuals with bulimia nervosa commonly employ in order to mange their weights.
Over-exercising may be another type of purging behavior that many individuals with bulimia nervosa engage in. Given our society’s emphasis on health, it is difficult to differentiate an individual’s intentions with exercise; however, if the sole purpose of the exercise is to compensate for the binging, it may be a sign of bulimia nervosa.
For example, one of my clients, who was part of a cross-country running team at her high school, used to run on average 30 miles each week, as part of her training. Additionally, she would go out three to five times each week after her binge episodes and swim for an additional two to three hours to compensate for the calories she ate. She fainted several times during practice due to her excessive exercise routine. Her coach referred her to me.
Excessive Valuation of Thinness
For many people with bulimia nervosa, their level of fitness and weight are strongly correlated with their sense of worth. Growing up in a highly critical family, Maria was exposed to fat-shaming language and often overheard her parents make negative comments about other people’s level of fitness and size from early childhood.
She internalized their voices and associated being “good” with being thin. Upon her birth she weighted within 70th percentile compared to her peers and she remained within the same range throughout her childhood. At school, she experienced lots weight shaming and bullying because of her weigh. Maria lost twenty-five pounds in the seventh grade after going on a high protein diet with her father. Although she regained the weight within seven months of coming off the diet, she told me that during that short period of time, she felt thin, and for the first time in her life, she truly felt accepted by her peers. But just like Maria, many individuals struggling with bulimia nervosa have weights that are within normal range.
Treatment of Bulimia Nervosa
Given the severity of Maria’s eating disorder, I continued working with her using a family-based treatment model that provided an opportunity for her parents to support her, by interrupting the binge/purge cycles. In our counseling sessions, we also addressed the family dynamics that contributed to the maintenance of Maria’s eating disorder.
Her collaboration with her family during her treatment allowed her to truly count on her parents for the first time in many years. She was able to develop more effective coping mechanisms to effectively address her anxiety and stress. With her newfound confidence in her support system and skills, she decided to accept the college admission she had earned, but she made the commitment to continue focusing on her recovery while she was away from her family.
Unlike Maria’s parents, many parents are in denial about the severity of their teens’ eating disorders. They often frame the eating disorder as a “phase.” Unfortunately, an eating disorder is a serious psychiatric symptom: in many cases it can even significantly compromise different organs of the body. Early intervention is a key for successful recovery, and it is important for parents to seek help when they observe the early signs of disordered eating behaviors.
Dr. Nazanin Moali is a clinical psychologist with a private practice in Los Angeles, California. She specializes in treating bulimia nervosa and anorexia nervosa in teens and adults and is passionate about helping her clients heal from eating disorders and live fulfilling, rewarding lives. She owns the Oasis2care practice in Torrance.